By Professor Greg Larkin
Professor of emergency medicine, University of Texas

Improved Accident and Emergency was the second priority voted for by viewers of Your NHS in 2002. US doctor and professor of emergency medicine Greg Larkin observes how certain American strategies could benefit this country.

Professor Larkin has worked in A&E in both the UK and the US

"Being British", as the Captain of the Titanic urged his fellow travellers, is a virtue that is famous the world over. It has long been associated with silent strength, quiet courage, and indefatigable fortitude.

But it may no longer be the survival advantage it once was, at least as far as waiting in Accident and Emergency (A&E) is concerned. In fact, "being British" may in part be responsible for the unwillingness of the Titanic-like NHS to change course.

As in Britain, the US emergency health system is itself in icy waters, grossly under-staffed, under-resourced, and over-subscribed. But it also has strengths which highlight key areas for potential improvement in the UK.

A&E Consultants

Having more senior staff not only reduces waiting times and improves quality of care, but also saves money

US emergency departments use around five times more consultant-level doctors than similar-sized UK A&Es.

And there is evidence that having more senior staff not only reduces waiting times and improves quality of care, but that it also saves money.

When the Johns Hopkins University Emergency Department put senior physicians at the front door, this improved speed and accuracy, decreased waiting times by 17%, and patient walkout rates fell by one-third, despite a 12% increase in patient volume.

The new consultant strategy saved the institution over $60,000 in decreased facility and nursing fees, even after absorbing the expensive salary and benefits of the physicians.

Litigation

Too few NHS trusts have a consultant-led emergency system with A&E specialists. And a high price is being paid as a result. The NHS Litigation Authority reports an enormous rise in claims, up more than 500% over the past six years.

Increased use of junior and locum doctors and nurses to staff A&E in the NHS puts the least experienced in charge of the most needy; a commonplace but clear-cut recipe for disaster.

Doctors in training need to learn under the tutelage of more senior doctors. Trial by fire at the patient's expense is not the way forward, particularly in life and death emergencies when the patient has little choice over who is caring for them.

The US has learned the hard way that a doctor's ability to reduce the risk of malpractice and injury to patients is proportional to the experience and skill of the emergency staff.

Staff safety

NHS Staff Survey

200, 000 of over one million NHS staff were surveyed

15% reported experiencing physical violence at work in the previous 12 months

67% of those who had experienced violence reported it

Source: Commission for Health Improvement, 2004

Related to the shortage of experienced A&E senior staff is the issue of A&E safety.

A recent survey suggests there are well over 100,000 violent incidents in NHS hospitals every year with 15% of doctors and nurses suffering assault at work. Most of these assaults and aggressive acts occur in A&E.

Not one of the 109 UK emergency nurses I interviewed in 2001 had been immune from physical threats of assault during the past year and nearly all (80%) had been struck physically by a patient at some time during their A&E tour of duty.

The very same week that Tony Blair proposed new "zero tolerance" measures to protect staff, one of our most delightful nurses was taken at knifepoint out into the A&E car park by a "patient."

Patient violence is a serious threat to keeping staff, but is currently underplayed and underreported in the NHS.

By taking this threat more seriously, much can be done to curb the tremendous attrition of A&E doctors and nurses in the UK. We simply have to do a better job of protecting our patients and our providers and here again there are lessons from America.

Hospital police

Every US emergency department around the country has police and/or security teams present

Nearly all US emergency departments have police and/or security teams present, 24/7. In addition to having club-like "bouncers", many urban emergency departments have metal detectors since firearms and, especially, knives are becoming more common.

Closed circuit TV, used in some A&Es, may be of little value. Being able to restrain dangerous patients from harming themselves and others is much more useful.

However unpopular in Britain, leather restraints for severely agitated patients are used routinely in the US and, when used by staff trained in the use of chemical sedation, they are very effective at protecting both patients and staff from harm.

Diagnostic equipment

Another issue related to speed and A&E wait times, is the shortage of staff and equipment for diagnostic tests.

US emergency doctors are able to assess patients' problems much more rapidly because they have enough scanners and x-ray personnel to keep the flow of patients going.

Patients that would be languishing in casualty queues in the UK or getting admitted needlessly are rapidly sent to theatre for surgery or back home, thus freeing up hospital beds for other patients.

Rapid access to quality emergency care can also curb serious illness such as asthma, infections, and cardiovascular diseases before they progress to more costly and morbid conditions.

Of course, equipment costs money, but according to the Chief Economic Advisor's office at the Department of Heath, A&E care comprises less than 2% of the total healthcare budget, similar to the US.

Efficient and effective A&E services can ease the burden elsewhere on an overstretched health service. High capacity A&Es, operating and scanning and seeing patients like a well-oiled machine 24/7, can allow smaller A&Es, community clinics and doctors' offices to close on nights, holidays, and weekends.

Getting what you pay for

Getting healthcare spending up to 10-12 % of GDP is a necessary evil for a modern healthcare system

You really do only get what you pay for. The UK simply doesn't invest enough in health services. While the US spends more than 15% of its Gross Domestic Product (GDP) on healthcare, in Britain it is approximately 8%.

Getting healthcare spending up to 10-12 % of the GDP as in most Western countries is a necessary evil for a modern healthcare system.

It may take approximately 10 years to adequately train enough physicians and nurses to staff the A&Es of the UK.

But especially in the wake of both 11 September, 2001, and 11 March, 2004, fortifying our neglected medical defences and frontline A&E services has never been more urgent.

As patients become more educated, they are likely to be more discerning about the quality of care they are receiving in A&E. "Being British" will give way to "being informed," which makes sense, since one day, we are all likely to be consumers of A&E services.

Professor Greg Larkin is a recent Atlantic Fellow in Public Policy and Visiting Professor at the Guy's, King's, and St. Thomas' School of Medicine, London. He is Professor of Surgery, Emergency Medicine, and Healthcare Management and Policy, at the University of Texas, Southwestern Medical School in Dallas.

He appeared on BBC One's Breakfast programme as part of the Your NHS event day, on Wednesday, 24 March, 2004.